LADoc00

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This will be my last post for quite awhile. I fear the coming changes due to the Health Care Bill will so fundamental to Pathology as to rival the very introduction of Medicare in 1965.

I still have no doubt that later in this decade or early in the next, Medicare and Medicaid itself will fall apart and the establishment of true multi-tiered health care system will unfortunately occur (Mayo Clinic has already dropped Medicare and Medicaid from its primary care mission, the remainder will follow mid decade I will predict). The middle class will be titanic losers in this process. The rich will retreat to smaller, exclusive medical arrangement with access to the full range of specialists on demand.

As I have had a decent university business education in my trials as a practice owner, I have a few assessments about what these changes will bring.

The big "Seachanges" to Pathology can be encapsulated in four points:
1.) the implementation of value-based purchasing
2.) the massive expansion of Medicaid rolls
3.) the massive reduction of Medicare spending
4.) the implementation of bundled Medicare payments

Any 4 of these are fairly calamitous individually for Pathology. All four of these simultaneously is literally the riding out of the 4 Horsemen.

To prevent a host of posts from idiot med students about how the poor and starving need medical care, I will reveal my own practice has never sent a single patient bill to collections. Ever. That means what people without insurance can pay I accept as payment be it 80% of the bill or 10% of the bill.

Do I feel they should pay nothing? No, of course not. That demeans me and you and our whole profession with a history dating back centuries.

I dont want to spend pages of text to go through the 4 points above and explain how they squeeze Pathology, I will leave it to you the readers to research the effects on your own.

I will explain how this will dramatically alter the current landscape:
~Consultations, now provided a separate CPT code that will essentially no longer exist, will evaporate. I predict sometime after the expansion of the bundled payment pilot in 2013 and its eventual adoption by private insurance, anyone who has a business model based on getting consults from other pathologists will have the lights turned out quite rapidly. This will actually be reinforced by the implementation of value-based purchasing analysis (which is set to begin sooner than 2013 I believe). Big losers: academic centers

~Molecular testing will undergo a massive contraction. Value-based purchasing and bundled payments will cause the near extinction of send out/esoteric testing. Cases for molecular analysis will be tightly limited to only those cases where there is a known treatment difference not prognostic one. The pathologist will become out of neccessity a tight filter for any expense not directly containable by the entity receiving the bundled payment. This will cause a seismic shift in the current independant laboratory world with such players as Quest Diagnostics etc. Big losers: reference labs

~Private practice pathologists who are practice owners with their own technical operation outside the hospital will face crisis. There are many large practices with free standing histology and immunohistochem businesses they rely on for a majority of their income. I do not feel these will survive the coming changes, either massive contraction or outright surrendering of the technical component to the entity/hospital getting the bundled payment. Big losers: private pathologists with histology labs

~Private practice pathologists in states where the corporate practice of medicine is illegal, such as California will face crisis. I do not believe private practice as it is now will exist by mid decade. Pathologists will become sub-contractors with a fixed reimbursement with which to pay expenses and their own salary. Basically, Pathologists will be left to negotiate their lump payment (no longer based on work as fee for service will die off) with hospitals. This is vastly worse than the NHS Brit model where doctors are paid government salaries BUT get government benefits, paid vacation and pensions. Big losers: private practice pathologists

~On the plus side, Pathology practices will no longer be able to charge any sort of buy in because their practice will simply have no resell value. This will definitely benefit younger, newer trainees. Winners: newly trained pathologists entering the workforce

~In order to maintain a level payment if at all possible, I expect the cases/pathologist to go astronomically high. This is very bad for job market in general as groups which have retirements will just contract and contract, working harder for the same chunk of their bundled payment. I would expect the mid to end decade to be one of the worst job markets for pathologists in history Losers: newly trained pathologists

~County facilities with massive medicaid populations will see a service explosion with the bill sent to state governors. This is very very bad unless you live in Texas (one of the few states with surplus). In California this is akin to the 2012 Apocalypse. I expect work volumes to literally go stratospheric and pay to go down by 50%+ or more. I expect newer hires to be excluded from cushy pension plans or special retirement benefits to keep down on cost. This will be a titanic battle with politicians, unions and doctors recreating Clash of the Titans in every major US city. County/public paid pathologists

~Relatively unaffected will be military physicians, physicians in VA hospitals, pathologists doing non-clinical work such as basic science research, forensics and government analysis. I do definitely expect academic salaries to be pushed down by the overall reduction in the comp analysis as well as the above issues. Perhaps more and more jr. staff being in the sub-100k/yr level.

Personally I would stay far away from niche areas like molecular testing. I would be incredibly careful about ANY debt you incur from education, training or whatever. Excessive education debt will be the millstone that destroys you and your family. Watch your debt payment:potential income ratio CAREFULLY.

As such do NOT overtrain, 1 fellowship is more than enough now.
I would favor broad training in AP/CP and not focused paths like AP/NP or AP/Dermpath. I would definitely favor AP/CP with no fellowship or AP+some soon to be worthless ABP certificate. Tommorrow's pathologist will need to sign out everything be it neuro, skin or bone marrow AND manage the lab.

Good luck and Godspeed to your destination:)

LADOC out.
 

2121115

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LADoc I always thought you added a lot to the board and I'm sorry to see you go. I hope that things aren't quite as doomsday as you make them out to be, but if so then "this is the life we chose". :)
 

path24

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LADoc...the voice of reason from the private world. Bummer.

Going to have to put up with more "hearts, fluffy clouds, and unicorn" pathology posts from academics/want to be academics. Bigger bummer.
 

Parts Unknown

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I'm going to go ahead and make my prediction. How reform will play out for pathology I have no idea. There are too many unknowns and too many variables for me to speculate (yet). In 1-2 years I think it will be much more obvious.

Anyways, in the grand sense I think this is going to play out similar to how Medicare played out. In the short term, the inception of Medicare created a veritable revenue river (forget stream) and harkened the so-called Golden Age of Medicine. In the next decade, with increased numbers of insured patients, unreimbursed (or under-reimbursed) care will decline rather than explode. Medicare's spending curve will be bent down, but only slightly. This will lead to a Silver Age of Medicine - not quite as awesome as Golden, but still surprisingly good.

It is during this period that I would recommend taking what you can, when you can, while you can. Diversify your portfolio, bury some gold in the basement, learn how to wield a 12 gauge, and pick up a couple of "fiesty" Dobermans.

By about 2020 cost controls on the partly private system won't be adequate anymore, and there will be no choice but to socialize insurance for >98% of the country. On that point I agree with LADoc 100%.
 

rirriri

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LaDoc00,

while i admire your generally pessimistic play on nearly everything i've seen here over the years, i think your assessment of the 'future' is taken with plenty of grains of salt.

every 10 years or so, physicians scream out that their incomes will crash and that all is going to hell----and sure things may get worse with red tape and/or restrictions---but all in all, there is a rubber-band strung mechanism of flexibility. It'll get sorted out....it always does, and it will again...

I think these issues should be looked at objectively and subjectively, however your political ties shouldn't be interfering with the outlook.

As for Pathologists being 'commodities'...it's already happened, mainly due to the raise-the-white-flat-don't-know-how-to-talk-and-communicate problem going on in the field. Pathologists just aren't bold enough and they really do have communication issues......it's changing, but far too slow.

You guys need to stop being so pessimistic. I know at least 10-15 graduates from fellowships over the past 3 years who have ALL gotten jobs...after 1 or 2 fellowships...good jobs, in good locations.....so i don't buy into the fluff that there are no jobs.

Use your energy to better the field to get involved with the administrative process in practices and hospitals, instead of just typing rants on forums.
 

malchik

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Don't know if you actually read the initial post or not rrirriririiririiri, but whether or not one agrees, it is pretty thoughtful and long on detail, while your last few posts seem to be of the fluff variety rather than his. For example, what specifically is this rubber band mechanism you speak of? There's optimism, there's pessimism, and then there's backing it up with at least some explanation if not data.
 

rirriri

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Don't know if you actually read the initial post or not rrirriririiririiri, but whether or not one agrees, it is pretty thoughtful and long on detail, while your last few posts seem to be of the fluff variety rather than his. For example, what specifically is this rubber band mechanism you speak of? There's optimism, there's pessimism, and then there's backing it up with at least some explanation if not data.
rubber band is nothing more than the rebound a field makes to regulation. You can't possibly expect that new regulations will be accomplished under the SAME set of rules or parameters for reimbursement that are being used currently right?

What I find consistently comical about the pessimistic conservative argument, is that it doesn't take into account the changes in the SURROUNDING interplay between institutions, divisions, departments, salaries, etc......in a time of flux, and in a time of altered payscales, there will be changes made by institutions to ensure that money gets allocated. A situation of change can't just be evaluated in a 'bubble'.

I've seen LaDoc00 write things like 50% and 75% reductions in salaries......that is PURELY COMICAL. There is nothing thoughtful or detailed about spewing rubbish like that....it's simply inflammatory and angry writing.

The truth is, these current changes WILL change the reimbursement of our work, however it remains to be seen what changes will COUNTERACT the initial adjustments...no one knows yet, because it hasn't begun yet. So why sit and speculate with knives in our pockets......it's a waste of time to get angry, instead of offer suggestions and constructive advice about how WE SHOULD be counteracting the upcoming rules and changes....
 

BamaAlum

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Rirriri,
I have followed this forum for a long time and I have always appreciated your posts. However I think you are being a little near sighted on this issue. While I think the doomsday scenario is premature, no one in pathology can honestly look at the coming changes and think that our reimbursement is not headed for a drop, perhaps a significant drop. The fact remains that this bill will have to be paid for as the cost projections for such a massive influx of patients will inevitably be far greater than anticipated. The easiest way to pay for this is on the backs of physicians. As Yaah rightly said, the original House bill included a permanent fix for the SGR, yet it was removed to maintain budget neutrality. The AMA lobbied heavily for the fix and was willing to support any bill as long as it included such a provision. They failed. Congress is obviously not overly concerned with appeasing physicians.

The Medicare bundling pilot project is destined to achieve significant cost savings so it is not a stretch to think that it will be expanded as a means to curtail costs. It is also not unreasonable to think that pathology in general is in a very poor position to negotiate with hospitals and other specialities for their slice of the bundle. Unlike surgery and our other clinical colleagues, we cannot take our patients elsewhere. There will always other pathology groups willing to step in and take the scraps thrown down from the table should we decide to walk away.

So, while I don't think pathologists will be lined up at soup kitchens anytime soon, to bury your head in the sand regarding this fundamental shift away from fee for service reimbursement is foolhardy and indicative of the nearsighted perspective that has placed pathology in such a position of weakness. The practice that I am about to join relies heavily on its own freestanding histology lab. Everyone in the practice in similarly concerned. None of us should make the mistake of thinking that since things have always worked out they will continue to do so.
 

rirriri

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Rirriri,
I have followed this forum for a long time and I have always appreciated your posts. However I think you are being a little near sighted on this issue. While I think the doomsday scenario is premature, no one in pathology can honestly look at the coming changes and think that our reimbursement is not headed for a drop, perhaps a significant drop. The fact remains that this bill will have to be paid for as the cost projections for such a massive influx of patients will inevitably be far greater than anticipated. The easiest way to pay for this is on the backs of physicians. As Yaah rightly said, the original House bill included a permanent fix for the SGR, yet it was removed to maintain budget neutrality. The AMA lobbied heavily for the fix and was willing to support any bill as long as it included such a provision. They failed. Congress is obviously not overly concerned with appeasing physicians.

The Medicare bundling pilot project is destined to achieve significant cost savings so it is not a stretch to think that it will be expanded as a means to curtail costs. It is also not unreasonable to think that pathology in general is in a very poor position to negotiate with hospitals and other specialities for their slice of the bundle. Unlike surgery and our other clinical colleagues, we cannot take our patients elsewhere. There will always other pathology groups willing to step in and take the scraps thrown down from the table should we decide to walk away.

So, while I don't think pathologists will be lined up at soup kitchens anytime soon, to bury your head in the sand regarding this fundamental shift away from fee for service reimbursement is foolhardy and indicative of the nearsighted perspective that has placed pathology in such a position of weakness. The practice that I am about to join relies heavily on its own freestanding histology lab. Everyone in the practice in similarly concerned. None of us should make the mistake of thinking that since things have always worked out they will continue to do so.

I won't deny that changes will come, however they will be gradual and done with alot more negotiation. to be honest, we are NOT in the first line of 'cuttable' expenses. I think to believe that laboratory diagnoses are in the firing line very early on in these changes is a big mistake. Pathology and laboratory medicine may also be used early on to be like 'proofchecking' of cost in medical care.....and whether the right diagnosis was being treated...

i don't see the doomsday at all, in fact i see this as an opportunity to work on fixing our field and trying to improve the red tape it can sometimes be entangled within.
 

wild0ne

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I've seen LaDoc00 write things like 50% and 75% reductions in salaries......that is PURELY COMICAL. There is nothing thoughtful or detailed about spewing rubbish like that....it's simply inflammatory and angry writing.
Agreed. It's hard to take a poster seriously when such nonsense is written in any part of his/her posts.

Few people deny that health care reform has the potential to adversely affect all physicians, including pathologists. But to use an abundance of superlatives (titanic, seismic, 4 horsemen, etc.) at this point seems to be premature and excessive (and comical).
 
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yaah

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I won't deny that changes will come, however they will be gradual and done with alot more negotiation. to be honest, we are NOT in the first line of 'cuttable' expenses. I think to believe that laboratory diagnoses are in the firing line very early on in these changes is a big mistake. Pathology and laboratory medicine may also be used early on to be like 'proofchecking' of cost in medical care.....and whether the right diagnosis was being treated...

i don't see the doomsday at all, in fact i see this as an opportunity to work on fixing our field and trying to improve the red tape it can sometimes be entangled within.
Part of the problem as I see it with medicine in the US is the overutilization of laboratory tests - i.e. excessive ordering. Inpatients get loads of tests every day that they don't need, and vague symptoms lead to numerous esoteric tests. This is only getting worse as new molecular and other tests come out which stratify risk or guide therapy. These tests are not going away. Pathology is in a position to do well if we can figure out a way to be appropriately compensated for these tests, but because many of them are likely to be bundled with other standard tests that presents problems.

The problem with many people on this forum (and with the country in general) is that everything becomes a doomsday scenario. Any change in the status quo (and sometimes even continuation of the status quo) is a dire warning which portends future disaster. When you exist in such a binary way, everything you are confronted with has to fit a binary way of thinking (i.e. disaster or benefit). The internet, with its natural tendency to be a repository for conspiracy theories and anonymous vitriole, is a natural place for these things to be deposited. What always gets lost in the shuffle is moderation and compromise. To many, compromise has become a sign of weakness or fallibility which also portends future disaster. Ironically, of course, failing to compromise and work things out is going to harm medical specialties all the more. Taking extreme uncompromising positions quickly leads to your own marginalization. One can either accept this reality or continue to fight it. If you choose the latter, it might make you feel better temporarily, and you can always blame someone else afterwards (the democrats, the academics, the media, right wing talk radio, whatever).

Paying attention to the future of our field is vitally important. But being an active participant as opposed to just a slogan-covered brick wall of obstinance is unhelpful, and I would suggest harmful. It is a lot easier to marginalize the obstinant and obnoxious. It is more difficult to marginalize the intelligent and informed who advocate strongly on behalf of their field, but recognize that the situation is more complicated than a few strongly-posited dire warnings and blanket statements.

I would encourage everyone in pathology (and in medicine in general) to stand up for yourself and educate yourself about your field. Stand up for yourself against those who seek to marginalize you. But equally as forcefully you should stand up for yourself against those who claim to be on your side yet have nothing to offer except rhetoric, and end up putting you out there as the true "enemy." The original post in this thread was indeed helpful and important to read, I agree, even if personally I think some of the conclusions were a little strong and dubious.
 

exPCM

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LADOC,
I wish you the best. You are one of the bright lights of SDN and you will be greatly missed.

I am constantly amazed by the complacency of other posters who seem to think that becoming a doctor always will be an automatic ticket to a comfortable life.
The golden days of the US and of US physicians have clearly passed. The task now is to successfully navigate the downward course.
http://www.infowars.com/how-did-america-fall-so-fast/
How Empires Fall

But Paul Farrel provides a bigger-picture analysis, quoting Jared Diamond and Marc Faber.

Diamond’s book ’s, Collapse: How Societies Choose to Fail or Succeed, studies the collapse of civilizations throughout history, and finds:

Civilizations share a sharp curve of decline. Indeed, a society’s demise may begin only a decade or two after it reaches its peak population, wealth and power…

One of the choices has depended on the courage to practice long-term thinking, and to make bold, courageous, anticipatory decisions at a time when problems have become perceptible but before they reach crisis proportions

And PhD economist Faber states:

How [am I] so sure about this final collapse?

Of all the questions I have about the future, this is the easiest one to answer. Once a society becomes successful it becomes arrogant, righteous, overconfident, corrupt, and decadent … overspends … costly wars … wealth inequity and social tensions increase; and society enters a secular decline.

[Quoting 18th century Scottish historian Alexander Fraser Tytler:] The average life span of the world’s greatest civilizations has been 200 years progressing from “bondage to spiritual faith … to great courage … to liberty … to abundance … to selfishness … to complacency … to apathy … to dependence and … back into bondage”

[Where is America in the cycle?] It is most unlikely that Western societies, and especially the U.S., will be an exception to this typical “society cycle.” … The U.S. is somewhere between the phase where it moves “from complacency to apathy” and “from apathy to dependence.”
 
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America is clearly in the selfishness phase. Just look at Wall Street and income disparities over the past decade or so. And look at the media and celebrity culture. Complacency has not set in. Everything these days is "me first" as is quite clearly evident on SDN as well. That's ok to a degree, we all have to think about ourselves to some extent.

While LADoc makes some good points, there is so much unknown in the health care saga right now. Health care is vitally important to this country, and that is highly unlikely to change. The question is how delivery will change. Part of this relates to technologic advances, part of it relates to willingness of the public to pay (for themselves and for others). Unfortunately the debate is being controlled on one side by the vocal minority who don't want to pay for anything yet want it all anyway, and on the other side who want everyone else to pay for everything. This country needs solid moderate leadership but is not getting it because everyone is entrenching. Does the country want to maintain great healthcare? Then we are going to have to pay more. Be honest with us.

Doctors are going to be suffering a bit but are still going to be vitally important. Healthcare in this country is not headed for its end, it is headed for something new. What that "new" is remains to be seen. To me, what the country needs to do is start taking profit motive and "shareholders" out of health care. Eliminate for-profit institutions. Eliminate incentives to do unnecessary procedures. Compensate doctors appropriately but don't tie it to garbage incentives and impossible-to-measure quality metrics. To do this, unfortunately, is going to require some government control. The free market is proving itself excellent in many ways, but is also leading to the proliferation of sleaze merchants in health care and health care delivery which includes far too many administrators, executive vice presidents, and non-medical consultants. The insurance industry is partly to blame but so are many others. How to eliminate the sleaze merchants and profiteers without turning healthcare into a government-run socialist mess is difficult, but it can be done if people actually are honest with each other and don't play political games.